Outcomes of HIV-positive patients with cryptococcal meningitis in the Americas.

BACKGROUND: Cryptococcal meningitis (CM) is associated with substantial mortality in HIV-infected patients. Optimal timing of antiretroviral therapy (ART) in persons with CM represents a clinical challenge, and the burden of CM in Latin America has not been well described. Studies suggest that early ART initiation is associated with higher mortality, but data from the Americas are scarce. METHODS: HIV-infected adults in care between 1985-2014 at participating sites in the Latin America (the Caribbean, Central and South America network (CCASAnet)) and the Vanderbilt Comprehensive Care Clinic (VCCC) and who had CM were included. Survival probabilities were estimated. Risk of death when initiating ART within the first 2 weeks after CM diagnosis versus initiating between 2-8 weeks was assessed using dynamic marginal structural models adjusting for site, age, sex, year of CM, CD4 count, and route of HIV transmission. FINDINGS: 340 patients were included (Argentina 58, Brazil 138, Chile 28, Honduras 27, Mexico 34, VCCC 55) and 142 (42%) died during the observation period. Among 151 patients with CM prior to ART 56 (37%) patients died compared to 86 (45%) of 189 with CM after ART initiation (p=0.14). Patients diagnosed with CM after ART had a higher risk of death (p=0.03, log-rank test). The probability of survival was not statistically different between patients who started ART within 2 weeks of CM (7/24, 29%) vs. those initiating between 2-8 weeks (14/53, 26%) (p=0.96), potentially due to lack of power. INTERPRETATION: In this large Latin-American cohort, patients with CM had very high mortality rates, especially those diagnosed after ART initiation. This study reflects the overwhelming burden of CM in HIV-infected patients in Latin America.

Phase II study of neoadjuvant chemotherapy in patients with surgically-proven, unresectable stage III non-small cell lung cancer.

BACKGROUND: The aim of this study was to assess whether patients with truly unresectable (bulky extracapsular N2, T4 for tracheobronchial angle or mediastinal organ invasion) stage III non-small cell lung cancer (NSCLC), as proven by cervical mediastinoscopy supplemented or not by left anterior mediastinoscopy and fiberoptic bronchoscopy or thoracotomy, could become resectable after induction cisplatin-containing chemotherapy. In addition, we studied the value of preoperatory magnetic resonance imaging (MRI), in evaluating the probability of achieving a radical resection after neoadjuvant chemotherapy. PATIENTS AND METHODS: Sixteen consecutive untreated stage III NSCLC patients were enrolled in the study. All the patients received two cycles of combination chemotherapy including cisplatin 100-120 mg/m2 intravenously (i.v.) days 1 and 22 and vinorelbine 30 mg/m2 i.v. days 1, 8, 15, 22 and 28 or vinblastine 5 mg/m2 i.v. days 1, 8, 15, 22 and 28. Thoracotomy was planned, after chemotherapy, for all non-progressive patients. No other treatment after surgery was devised following radical resection and patients with residual disease after surgery received standard post-operative radiotherapy. Response to treatment was evaluated by thorax CT and MRI two weeks after the last administration of chemotherapy. RESULTS: The overall complete resection rate was 38% (6 out of 16 patients). MRI was predictive of complete resectability in 80% of cases. In fact, 6 patients judged resectable were completely resected, 3 patients judged unresectable underwent only explorative thoracotomy or incomplete resection while MRI was unpredictive only in one case. The most important chemotherapy-related toxicity was hematological: eight patients (50%) had grades III-IV leukopenia. CONCLUSION: These results indicate that preoperative second generation cisplatin-based chemotherapy can make resectable truly unresectable stage III NSCLC patients in only 38% of cases and that MRI is a reliable tool for assessment of radical resection probability after neoadjuvant chemotherapy.

[Combined multimodal treatment for liver and lung metastasis from colorectal cancer: a new therapeutic option?]. / Il trattamento multimodale combinato delle metastasi epatiche e polmonari da cancro colorettale: una nuova opzione terapeutica?

The authors analyse which therapeutic strategy to adopt on the basis of prognostic factors and staging of hepatic and pulmonary metastases from colorectal cancer. They underline the effectiveness of combined multimodal therapy in the treatment of very advanced metastatic stages. 218 patients with metastases from colorectal cancer (12 pulmonary and 206 hepatic metastases) were treated from January 1980 to October 2000. Among these patients, 159 underwent surgery (4 pulmonary and 155 hepatic resections), 16 were reoperated on for metastatic relapse, 14 with multiple metastases underwent locoregional therapy and 29, deemed unresectable initially, were treated with neoadjuvant chemo- and radiotherapy. In the operated patient group the 5-year actuarial survival rate was 22% with an operative mortality of 3.8% and a morbidity of 17.5%. The 16 patients reoperated on for metastatic relapse had a 5-year actuarial survival of 21% with an operative mortality of 6.2% and a morbidity of 15.8%. The 14 patients treated with locoregional therapy had a median survival of 6 months whereas the 29 patients treated in two different periods with combined multimodal treatment had a response rate of 59.2%. Five patients had a complete response and 4 are currently disease-free. Surgical resection is at present the best known treatment for metastatic disease. In very advanced, as yet undisseminated stages, in which there is no surgical indication for metastases a neoadjuvant treatment is proposed if the primary tumour has already been completely resected. The aim of this therapeutic strategy, called combined multimodal therapy, is to obtain the disease regression with the aid of systemic chemo- and radiotherapy and to offer a chance of re-staging the disease.

Peritoneal abscess formation as a late complication of gallstones spilled during laparoscopic cholecystectomy.

The case is described of a 74-year-old woman who presented with an abdominal abscess 1.5 years after laparascopic cholecystectomy. CT and ultrasound showed the presence of gallstones within the abscess. Spillage of gallstones from perforation of the gallbladder is a well recognized complication of laparascopic cholecystectomy, although subsequent abscess formation is unusual especially after a long delay as in this case.

Combined cisplatin, doxorubicin, and mitomycin for the treatment of advanced pleural mesothelioma: a phase II FONICAP trial. Italian Lung Cancer Task Force.

BACKGROUND: In a previous FONICAP trial, the combination of doxorubicin (D) and cisplatin (P) yielded an objective response rate of 25% and a subjective response rate of 50% in patients with mesothelioma. In human mesothelioma cell lines, mitomycin (M) showed a synergic activity with P and in a recent randomized study, the combination of M and P showed slightly superior activity when compared with the PD regimen. METHODS: The authors tested the activity and toxicity of a combination chemotherapy regimen including P, 60 mg/m2, D, 60 mg/m2, and M, 10 mg/m2, all by intravenous infusion on Day 1 every 28 days in a Phase II study. RESULTS: Twenty-four chemotherapy-naive mesothelioma patients were enrolled in the study. Patient characteristics were the following: the median age was 58 years; the median performance status was 1; there were 6 Stage I patients, 15 Stage II patients, 2 Stage III patients, and 1 Stage IV patient; and 10 patients had previous asbestos exposure. All patients had pretreatment symptoms: 13 had chest pain, 9 had pleural effusion, and 7 had dyspnea. A total of 78 cycles of chemotherapy were administered. The only significant side effect was myelosuppression, with only 9.5% of patients having Grade 4 toxicity. Among 23 patients evaluable for response, 5 achieved a partial response (20.8%; 95% confidence interval, 7.1-42.1%), 9 had stable disease, and 9 had progressive disease (including 1 early death). One patient was not evaluable because of treatment refusal. A clinical improvement was observed in 7 of 24 patients (29%). CONCLUSIONS: The combination of PDM in patients with pleural mesothelioma is feasible and moderately active. However, the observed level of activity is similar to that obtained with other two-drug regimens.

Transudative vs exudative pleural effusions: differentiation using Gd-DTPA-enhanced MRI.

The aim of this study was to investigate the capability of Gd-DTPA-enhanced MRI to differentiate between exudative and transudative pleural effusions. An MRI examination was performed on 22 patients with different types of pleural effusion (10 transudative and 12 exudative effusions). T1-weighted SE images were obtained before and 20 min after administration of Gd-DTPA (0.1 mmol/kg). The degree of enhancement of pleural effusions was evaluated both by visual assessment and by quantitative analysis of images. None of 10 transudative effusions showed significative enhancement, whereas 10 of 12 exudative effusions showed enhancement (sensitivity 83 %, specificity 100 %, positive predictive value 100 %). The postcontrast signal intensity ratios (SIRs) of exudates were significantly higher than corresponding precontrast ratios (P = 0. 0109) and the postcontrast SIRs of exudates were significantly higher than those of transudates (P = 0.0300). Exudative pleural effusions show a significant enhancement following administration of Gd-DTPA. We presume that this may be caused by increased pleural permeability and more rapid passage of a large amount of Gd-DTPA from the blood into the pleural fluid in case of exudative effusions. In our limited group of patients, signal enhancement proved the presence of an exudative effusion. Absence of signal enhancement suggests a transudate, but does not exclude an exudate.

CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery.

OBJECTIVE: Postthoracotomy atrophy of chest wall muscles results from nerve injury during surgery. After encountering patients with different patterns of chest wall muscular atrophy postthoracotomy, we performed this study to determine the relationship between type of thoracotomy and atrophic muscles as seen on CT scans. MATERIALS AND METHODS: CT scans of 58 patients who had previously undergone unilateral thoracotomy were reviewed. Forty patients had a posterolateral thoracotomy, and 18 had an anterolateral thoracotomy. In two cases, the incision extended posteriorly. Atrophy seen on CT scans was defined as a marked decrease in size or thickness of a muscle compared with the muscle on the other side. RESULTS: Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle was detected on CT scans in 40 patients. No atrophy was found in 16 patients. The remaining two displayed atrophy only in the serratus anterior muscle. Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle developed in all patients who had a posterolateral thoracotomy. Atrophy developed in only two of the 18 patients who had an anterolateral thoracotomy, and in these two, the incision had been extended posteriorly. CONCLUSION: A direct correlation was found between type of thoracotomy and site of atrophy of the chest wall muscles seen on CT scans. This finding may account for different CT appearances of the thoracic wall in patients who have had thoracic surgery.

Case report: bowel infarction with splenic air embolism: computed tomography findings.

Computed tomography (CT) is used increasingly as an early radiological examination in patients with suspected bowel infarction because it provides information about the intestinal wall, mesenteric circulation and peritoneal cavity [1, 2]. Other disorders that present with similar symptoms such as intraabdominal abscess, pancreatitis and ulcerative colitis can be excluded [3]. CT can demonstrate small amounts of air within the bowel wall, in the spleno-mesenteric-portal venous system and in the peritoneal cavity, making it possible to differentiate portal venous gas from pneumobilia. The authors describe a patient in whom a specific diagnosis of bowel infarction was made on the characteristic CT findings. Furthermore, air embolism was observed in the splenic parenchyma. This finding has not been previously reported in bowel infarction or in any other abdominal disorder.

[Role of computerized tomography in the evaluation of extraductal extension of hilar cholangiocarcinoma]. / Ruolo della tomografia computerizzata nella valutazione dell'estensione extra-duttale del colangiocarcinoma ilare.

This study was aimed at assessing the role of CT in the investigation of extraductal spread of hilar cholangiocarcinoma. October 1990 to November 1993, twenty-one patients with hilar cholangiocarcinoma were examined. The diagnosis was made on the basis of the following CT findings: intrahepatic bile ducts dilatation, nonunion of the right and the left bile ducts, normal size of extrahepatic bile ducts and the tumor depicted "per se". As for extraductal spread, we considered parenchymal invasion, involvement of vascular structures and parenchymal, lymph node and peritoneal metastases. In all cases CT demonstrated intrahepatic bile duct dilatation and nonunion at the confluence. CT demonstrated a hypodense mass in 10/21 cases and an isodense mass in 11/21 cases. Portal vein involvement was detected in 7/10 cases and hepatic artery involvement was correctly suspected in 1/8 cases; CT demonstrated parenchymal and lymph node metastases in 1/6 and 2/7 cases. In conclusion, CT proved to be a valuable technique, like PTC and US, to assess tumor resectability.

[Blunt hepatic and splenic trauma: indications for conservative treatment based on computerized tomography]. / Traumi epatici e splenici chiusi: indicazioni con tomografia computerizzata al trattamento conservativo.

In this paper the authors try to define CT criteria for the evaluation of hepatic and splenic injuries in blunt abdominal traumas, to suggest and guide the nonoperative management of trauma in hemodynamically stable patients. The predictive value of CT on the outcome of the nonoperative treatment in adult patients with blunt hepatic and splenic trauma is trusted more and more also thanks to the good results of conservative management in similar injuries in pediatric patients. Thus, we reviewed 314 emergency abdominal CT scans performed in our center March 1990 to March 1992. The hepatic and splenic injuries detected on CT scans were evaluated according to a CT-based injury classification in grades, with a score reflecting progressive severity of lesions. Moreover, the presence of intraperitoneal hemorrhage was determined and quantified on the basis of a standard classification system. Of 314 cases, CT revealed blunt hepatic injury in 17 patients and blunt splenic injury in 38. We excluded the patients who exhibited, besides the hepatic or splenic injury, other severe visceral lesions which might need surgery. Nonoperative management was attempted in 9 of 17 patients with hepatic injury and in 4 of 38 patients with splenic injury detected by CT; the scores given according to the above classification system were compared with the clinical outcome. The results indicate that hepatic injuries up to and including grade III, as assessed by CT, can be successfully managed without surgery in hemodynamically stable patients. As for splenic traumas, nonoperative management was attempted in a very small number of patients. Even though a case of grade-III splenic injury in our series was successfully treated without surgery, this may not be the rule, because the outcome of splenic injury and of intraperitoneal hemorrhage is often unpredictable.

[The magnetic resonance characteristics of rounded atelectasis]. / Aspetti caratteristici dell'atelettasia rotonda alla risonanza magnetica.

Rounded atelectasis is a peculiar form of lung collapse which is well known by radiologists. Its appearance on conventional radiographs and CT is by now well recognized and widely reported. Even though these two techniques usually allow a diagnosis to be made, the MR appearance of rounded atelectasis is worth mentioning as well. This diagnostic imaging technique is widely employed, and our experience suggests that, in some cases, MR Imaging can give an important contribution to the study of this condition. We report our experience with 6 cases of rounded atelectasis in 5 patients (one patient had bilateral lesions). Five signs characteristic of rounded atelectasis were observed: some of them are seen on both conventional radiographs and CT scans, others are typical of the latter technique. All cases showed peripheral location of the lesions and the "comet tail" sign--i.e., vascular structures gently curving into the mass. These two signs are also observed on conventional radiographs and CT scans. Typical of MR imaging are the extant 3 signs: low signal in T1 and high signal in T2-weighted images in the whole of our cases; no signal from pleural thickening next to the mass in T2-weighted images, and, finally, the "kidney-like" pattern--i.e., hypointense lines converging toward the center of the mass. All these signs, which were always observed in our series, support the current etiopathogenetic hypothesis of pleural effusion as an early sign, which is reported to be followed by fibrous pleural involution which wraps atelectatic parenchyma up. On the basis of these typical MR features a correct diagnosis can usually be made even in those cases in which conventional radiography and CT do not allow a definite diagnosis.

Chest wall involvement by lung cancer: computed tomographic detection and results of operation.

The aim of this prospective study was to evaluate: (1) the role of computed tomographic scanning in predicting chest wall invasion by peripheral lung cancer and (2) the results of operation according to the depth of chest wall involvement and other potential indicators of long-term survival. One hundred twelve patients with non-small cell lung cancer adjacent to the pleural surface who underwent computed tomographic scanning and subsequent thoracotomy were entered into this study. Tumor invasion was confined to the visceral pleura in 53 patients, to the parietal pleura in 18 patients, and to intercostal muscles in 25 patients; invasion extended beyond this layer in 16 patients. The computed tomographic criteria for chest wall invasion were (1) obliteration of the extrapleural fat plane, (2) the length of the tumor-pleura contact, (3) the ratio between the tumor-pleura contact and the tumor diameter, (4) the angle of the tumor with the pleura, (5) a mass involving the chest wall, and (6) rib destruction. The computed tomographic criteria 1 and 3 were significantly related to pathologic findings. Sensitivity was 85% for criterion 1 and 83% for criterion 3, specificity being 87% and 80%, respectively. Long-term survival of patients with T3 disease critically depended on the lymph node state and completeness of resection. The adenocarcinoma cell type and the T4 category were unfavorable prognostic factors. The depth of chest wall invasion did not affect survival, except for extensive rib and soft tissue infiltration. En bloc resection yielded better results than discontinuous resection.

[Magnetic resonance imaging of low intensity field in the follow-up of pneumonectomized patients]. / La risonanza magnetica a bassa intensità di campo nel follow-up dei pazienti pneumonectomizzati.

The authors investigated the real contribution of low-field MR imaging in the follow-up of pneumonectomized patients. Literature on the subject is surprisingly poor, even though MR diagnostic capabilities seem to be great in these patients. Because of the peculiar anatomical features of pneumonectomized patients, low-field MR imaging yields high-quality images. The operated hemithorax, with the postpneumonectomy space full of fluid, in the absence of respiratory movements is free of movement artifacts. The latter are known to worsen image quality in thoracic MR imaging, especially without respiratory gating. In the study of mediastinum and operated hemithorax MR imaging provides the highest diagnostic contribution. In the mediastinum MR images demonstrate enlarged lymph nodes and tumor recurrences and is superior to CT especially when great vessels are involved. In the study of the operated hemithorax, MR imaging is preferable to CT to identify parietal lesions, because of its higher spatial resolution. Moreover, MR imaging allows tumor recurrences to be differentiated from normal muscular tissue and from fibrous tissue on the basis of their different signal intensities as observed on the various pulse sequences.

Improving clinical efficacy of computed tomographic scan in the preoperative assessment of patients with non-small cell lung cancer.

The criterion of choice for computed tomographic scan identification of metastatic mediastinal nodes is not clearly fixed. This prospective study was designed to define the most suitable computed tomographic criterion for detection of nodal metastasis, enabling improvement of the test's clinical efficacy. One hundred twenty-three patients with potentially operable non-small cell lung cancer underwent mediastinal evaluation by computed tomographic scan and cervical mediastinoscopy followed by thoracotomy with mediastinal node dissection. There were 116 men and seven women; the mean age was 59.3 +/- 9.1 years. Forty-six tumors were classified after operation as stage I, 20 as stage II, 27 as stage IIIa, and 30 as stage IIIb. Mediastinal nodes were classified as metastatic according to the following computed tomographic scan criteria: (1) shorter axis 1 cm or larger; (2) shorter axis 1.5 cm or larger (nodes less than 1 cm were classified as negative and those 1 to 1.5 cm as indeterminate); and (3a) shorter axis 1 cm or larger, plus evidence of central necrosis or discontinued capsule, or (3b) shorter axis 2 cm or more, regardless of the nodal morphologic condition. The highest sensitivity rate was achieved by using criterion 1 (90%) and the poorest by criterion 3 (75%). The greatest specificity rate was obtained by applying criterion 3 (90%) and the lowest by criterion 1 (54%). The prediction by using computed tomographic criterion 3 correlated better with pathologic findings than that derived by adopting the criterion 1 or 2. When mediastinal nodes were identified as negative according to criterion 1, 2, or 3, the complete resection rate was 92%, 92%, or 95%, respectively, rendering cervical mediastinoscopy unnecessary. When mediastinal nodes were classified as positive, the resectability rate was 55%, 27%, or 13%, respectively. In these instances cervical mediastinoscopy allowed identification of different degrees of mediastinal involvement; it proved to be the most useful procedure for preoperative selection of those patients with N2 tumors who are amenable to a complete resection. In conclusion, the use of computed tomographic criterion 3 does improve the clinical efficacy of the test, by sparing a large number of unnecessary mediastinal explorations, without increasing the rate of useless thoracotomies.